青少年型锁定髓内钉治疗儿童股骨干骨折的疗效

目的 评估青少年型锁定髓内钉治疗儿童股骨干骨折的疗效.方法 采用经大转子外侧置入锁定髓内钉治疗21例儿童股骨干骨折.评估患侧髋、膝关节的功能,测量双下肢长度、股骨颈干角及股骨颈直径,记录切口感染、股骨头缺血性坏死、髋外翻和股骨颈狭窄等并发症发生情况.结果 患儿均获得随访,时间8～34个月.骨折均愈合,时间10～28周....     

Femoral lengthening over a humeral intramedullary nail in preadolescent children

BACKGROUND: Femoral lengthening over an intramedullary nail has been described in adults. A technique of femoral lengthening over a humeral intramedullary nail in children is described, and the results and complications are presented. METHODS: Nine preadolescent patients (average age, nine years and ten months) with femoral length discrepancy were treated with femoral lengthening over a humeral intramedullary nail. After nail insertion, a monolateral external fixator was placed with half-pins either anterior or posterior to the intramedullary nail, and lengthening was performed through a proximal osteotomy. RESULTS: The femora were lengthened a mean of 6.1 cm (range, 5.0 to 8.0 cm), 19.5% (range, 15.9% to 26.2%) of the preoperative femoral length. Patients had a mean lengthening index of 12.2 days/cm of length (range, 9.5 to 16.9 days/cm of length). Five complications including osteomyelitis, failure of the distal interlocking site, and femoral fracture at the distal end of the nail occurred in four patients; four of the complications led to surgical intervention. No case of proximal femoral valgus secondary to nailing through the greater trochanter had developed by the time of final follow-up. All patients were followed for a minimum of two years postoperatively, with a mean of 128 weeks (range, 111 to 161 weeks). CONCLUSIONS: The technique is effective but has a high rate of complications, including osteomyelitis, which developed in two of the nine patients. No avascular necrosis or proximal femoral valgus was noted.     

Intramedullary nailing of femoral shaft fractures in children via the trochanter tip

Closed rigid intramedullary nailing of femoral shaft fractures in children has been associated with avascular necrosis of the femoral head. Avascular necrosis of the femoral head is thought to result from damage to the medial femoral circumflex artery by placing the nail through the piriformis fossa. The authors describe the early results of a technique in which the nail is placed through the tip of the greater trochanter, thus avoiding the piriformis fossa and possible damage to the medial circumflex artery. Between 1988 and 1995, the authors performed this procedure on 34 patients, who ranged in age from 10 years 2 months to 17 years 6 months. Followup time ranged from 1 month to 120 months. There were no infections, nonunions, rotational deformities, or implant failures. Twenty patients with open physes had a followup of 2 years or more. To date, no patient had avascular necrosis of the femoral head develop. The trochanteric tip entry point is recommended for closed rigid intramedullary nailing of femoral shaft fractures in children and adolescents.     

Diaphyseal derotational osteotomy with intramedullary fixation for correction of excessive femoral anteversion in children

Nearly all children with femoral anteversion spontaneously remodel by age 8. Femoral derotational osteotomies are performed in older children with persistent excessive femoral anteversion when children or adolescents are limited in activities of daily living or sports. Procedures for correction of the anteversion vary, and no one procedure has been shown to be superior. Since 1997 the authors have corrected idiopathic excessive femoral anteversion thorough a diaphyseal osteotomy with fixation using a rigid intramedullary pediatric femoral nail. The purpose of this study was to describe the technique and results of this new technique. A retrospective study was conducted of all femoral derotational osteotomies performed with a pediatric femoral nail in 13 consecutive patients and 21 affected limbs. All patients complained preoperatively of frequent tripping during sports and activities of daily living. The mean preoperative rotation included internal rotation of 77 degrees and external rotation of 15 degrees. Standing AP radiographs of all patients were obtained at final follow-up. All patients were evaluated clinically and radiographically at a minimum of 1 year after surgery. All patients noted improvement in the ability to participate in activities without tripping. No patient limped at final follow-up. No intraoperative or postoperative complications occurred. Healing of the osteotomy was present at a mean of 6 weeks. All osteotomies healed in anatomic alignment. Mean final hip rotation included internal rotation of 40 degrees and external rotation of 57 degrees. No patient had substantial changes of valgus or femoral neck narrowing at final follow-up. Femoral derotational osteotomy with fixation using a small-diameter rigid intramedullary nail placed through the lateral aspect of the greater trochanter is a safe, accurate, and effective method of correcting excessive femoral anteversion in symptomatic children.     

Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children

BACKGROUND: Recent reports have described osteonecrosis of the femoral head after intramedullary nailing of the femur through the piriformis fossa in children. Other reports have raised concerns about the development of femoral neck narrowing and valgus deformity of the proximal part of the femur after intramedullary nailing through the tip of the greater trochanter. We evaluated the radiographic changes in the proximal part of the femur following intramedullary nailing through the lateral trochanteric area at a minimum of two years postoperatively in twenty-five affected extremities. The mean age of the patients at the time of the index procedure was ten years and six months. METHODS: A retrospective radiographic review was performed to look for proximal femoral changes. Specifically, the radiographs were examined for evidence of osteonecrosis. The articulotrochanteric distance, femoral neck diameter, and neck-shaft angle were measured on the initial and final radiographs. RESULTS: No patient had evidence of osteonecrosis of the femoral head. The articulotrochanteric distance decreased by a mean of 0.4 mm, the femoral neck diameter increased by a mean of 4.9 mm, and the neck-shaft angle decreased by a mean of 1.4 degrees. Compared with a group of seventeen patients with adequate initial and final radiographs of the contralateral side, the final mean articulotrochanteric distance was 4.5 mm less on the involved side than on the uninvolved side, the mean femoral neck diameter was 0.7 mm less on the involved side than on the uninvolved side, and the mean neck-shaft angle was 3.2 degrees less on the involved side than on the uninvolved side. No patient had development of clinically important femoral neck narrowing or valgus deformity. Statistically, the likelihood that these data represent a group with a mean 3-mm increase in the articulotrochanteric distance is <1%. The likelihood that these data represent a group with a mean 3.2-mm decrease in the ultimate femoral neck diameter is <1%. The likelihood that these data represent a group with a mean 5 degrees increase in the neck-shaft angle is <1%. CONCLUSIONS: Lateral transtrochanteric intramedullary nailing in children who are nine years of age or older does not produce clinically important femoral neck valgus deformity or narrowing, and we did not observe osteonecrosis of the femoral head after this procedure.     

Ipsilateral fractures of the femoral neck and shaft.

Thirty-three patients with ipsilateral intracapsular femoral neck and shaft fractures were treated with antegrade reamed intramedullary (IM) nails and cancellous screw fixation of the femoral neck. The shaft fractures were fixed prior to definitive neck stabilization. A "reversed" nail construct was used in 13 patients, a conventional interlocked nail was used in 6, and a reconstruction nail was used in the remaining 14. Thirty-one (94%) of the femoral shaft fractures healed primarily. In two patients, the shaft fracture failed to unite and was bone grafted and plated, respectively; the fractures subsequently healed. However, only 27 (82%) of the femoral neck fractures healed after initial fixation. In six patients (18%), a symptomatic varus nonunion developed, requiring a valgus osteotomy. Five of the six femoral neck non-unions and all of the osteotomy sites united; however, two of these patients later developed osteonecrosis of their femoral heads. Closed reamed antegrade IM nailing with supplemental screw fixation of ipsilateral femoral neck and shaft fractures did not produce uniformly successful results because of high rates of varus nonunion of the femoral neck fracture.     

Closed, locked intramedullary nailing of pediatric femoral shaft fractures through the tip of the greater trochanter

BACKGROUND: Closed femoral nailing is universally accepted as the treatment of choice in almost all diaphyseal femoral fractures in adults. Numerous authors reported favorable results applying the same surgical technique in the adolescent patient group. Nevertheless, reports of complications such as avascular necrosis and alteration of the proximal femoral anatomy have dampened the initial enthusiasm. The purpose of this paper was to evaluate the possible effect of closed intramedullary nailing through the greater trochanter on the proximal femoral anatomy. METHODS: We report the results of intramedullary nailing in 20 skeletally immature patients (13 men and 7 women) with a mean age of 14.4 years (range, 11-16 years). All were treated with closed, reamed, percutaneously performed nailing, using the tip of the greater trochanter as the nail insertion point. The patients were followed for 29 months in average (range, 19-37 months). RESULTS: No major complication (limb length discrepancy, avascular necrosis, coxa valga) occurred during the observation period. All fractures healed clinically and radiographically within 9 weeks in average (8-13 weeks) and all patients returned to the preinjury activity level. The mean ATD difference was 1.10 +/- 3.51 (range, -5-7 mm, 95% CI -0,54/2,74, p = 0.177). The mean LTA distance difference was 0.3 mm (range, -6-5 mm, p = 0.158), the mean femoral length difference was 1.9 mm (-9-12 mm, p = 0.122) and the overall limb length difference was 1.4 mm (-25-20 mm, p = 0.178). The mean neck-shaft angle difference was 0.20 +/- 1.74 (range, -3-4, p = 0.612) and the mean neck width was 0.60 +/- 1.50 (range, -3-3, p = 0.09). Fourteen nails (70%) were removed within 13 months in average (range, 10-18 months) without any complications. CONCLUSION: This study showed that with strict adherence to a surgical technique that respects the growing proximal femur and its vascular anatomy, using the tip of the greater trochanter as an entry point to the femoral canal, the proven advantages of closed, intramedullary nailing can safely be offered to the adolescent patient population as well.     

Femoral shaft fractures: is rigid intramedullary nailing safe for adolescents?

Despite recent reports of avascular necrosis of the femoral head after intramedullary nailing in children, this fixation method is still being advocated for the treatment of femoral shaft fractures. In this article, we report a case of early-onset, severe, symptomatic avascular necrosis of the femoral head after intramedullary nailing in a 13-year-old boy. Given the possibility of this devastating complication, surgeons should consider the risk-benefit ratios of various techniques for managing femoral shaft fractures in adolescents.     

Antegrade rigid nailing through the tip of the greater trochanter for pediatric femoral shaft fractures

The aim of this work was to evaluate the results of rigid nailing of pediatric femoral shaft fractures inserted antegrade through the tip of the greater trochanter. Twenty-three femoral shaft fractures in 23 children were fixed with rigid interlocking nails inserted through the tip of the greater trochanter at Mansoura Emergency Hospital in the period between June 2009 and August 2011. The average age of the patients at the time of injury was 12.6 years (range 9.2–15 years). The final follow-up radiographs were assessed for evidence of avascular necrosis (AVN) of the femoral head and any deformity of the proximal femur, the neck–shaft angle, the articulotrochanteric distance, and the femoral neck diameter. Patients were followed to a mean period of 31 months (range from 25 to 36 months) postoperatively. All fractures united in a range of 9 weeks (from 8 to 13 weeks) with no limb length discrepancy more than 2 cm and no clinically evident rotation in either direction; no case had a vascular necrosis of the femoral head or significant proximal femoral deformity by the final follow-up. Fixation of fractures of the shaft of the femur in children with rigid interlocking nails inserted through the tip of the greater trochanter is a rigid way for fixation controlling rotation and length. It is a safe technique without causing AVN of the femoral head or proximal femoral deformity.     

Initial experience with a second generation locking femoral nail: the Russell-Taylor reconstruction nail

A series of 36 patients with 20 subtrochanteric fractures, 12 ipsilateral neck/shaft fractures, and five intertrochanteric fractures with shaft extension underwent closed intramedullary nailing with the Russell-Taylor reconstruction (RECON) nail. The average Injury Severity Score was 16, and seven of the fractures were open. All fractures were acute injuries, and all but one were treated within 24 hours of admission. Follow-up was obtained at three, six, nine, 12, and 24 months or until the fracture healed. The range of follow-up was one to three years. Complete follow-up was obtained in 33 of 36 patients. Union was achieved in all acute fractures. Shortening occurred in two cases and chondrolysis and avascular necrosis occurred in another patient. Excellent hip and knee range of motion were obtained except in a few cases of ipsilateral limb injuries. While many complex femoral shaft fractures can be treated successfully with first generation locking nails, this study demonstrates that second generation locking nails, such as the RECON nail, offer the added strength and design features necessary for more effective treatment of complex proximal and ipsilateral femoral neck/shaft fractures.     

肱骨干骨折顺行与逆行髓内针固定的病例 对照研究

目的：比较肱骨干骨折顺行与逆行髓内针固定的疗效。方法：入选1999年3月至2006年10月间有完整随访资料的肱骨干骨折105例,分为顺行髓内针组（A组）82例,逆行髓内针组（B组）23例。对两组的手术时间、术中出血量、并发症发生率、骨折愈合时间、骨折愈合率、Constant—Murley肩关节功能评分和Mayo肘关节功能评分等指标进行比较。结果：随访时间平均（31．2±20．9）个月。两组的手术时间、骨折愈合时间、愈合率及并发症发生率比较差异无统计学意义（P〉0．05）。B组术中出血量大于A组（P=0．002）。A组有4例（4．9％）不愈合,8例（9．8％）发生肩痛伴肩关节活动度减小,B组3例（13．0％）术中发生医源性骨折。A组肩关节功能评分低于B组（P=0．04）,肘关节功能评分两组比较差异无统计学意义（P〉0．05）。结论：顺行与逆行髓内针固定均是治疗肱骨干骨折的有效方法,但逆行髓内针固定医源性骨折发生率较高,应正确选择和制备髓内针入点。顺行髓内针固定有较高的肩痛和肩关节活动度减小的并发症发生率,注意将髓内针尾埋于肩袖下方,细致保护和修复肩袖,术后进行合理的康复练习,有利于减少肩痛和改善肩关节功能。     

Ipsilateral femoral neck and shaft fractures: complications and their treatment

An ipsilateral femoral neck fracture occurs in approximately 6% to 9% of all femoral shaft fractures. Despite this relatively common presentation, decision-making often is difficult. Furthermore, the risk for complications is greater in the treatment of this combination injury pattern than for single-level fractures. A retrospective review of the authors' large trauma database revealed 13 patients who had healing complications develop after their index surgical procedure. Six of the eight (75%) femoral neck nonunions occurring in these 13 patients developed after the use of a second generation, reconstruction-type intramedullary nail. Factors contributing to nonunion of the femoral shaft were the presence of an open fracture, use of an unreamed, small diameter intramedullary nail, and prolonged delay to weightbearing. The femoral neck nonunions healed after either valgus intertrochanteric osteotomy (seven patients) or compression hip screw fixation (one patient). The femoral shaft nonunion proved more difficult than expected to treat with some patients with femoral shaft nonunions requiring more than one operative procedure to achieve union. Lag screw fixation of the femoral neck fracture and reamed intramedullary nailing for shaft fracture stabilization were associated with the fewest complications. Therefore, this approach is recommended as the treatment of choice.     

Treatment of severely displaced proximal humeral fractures in children with elastic stable intramedullary nailing

We report on our 8-year experience of using elastic stable intramedullary nailing for severely displaced proximal humeral fractures in children. Fourteen patients (mean age 13.4 years) with seven epiphyseal and seven metaphyseal fractures underwent intramedullary nailing, using single nail fixation in 12 cases. Clinical and radiological healing was achieved at 2.4 and 3.2 months, respectively. Complications included temporary shoulder and elbow stiffness in one and four cases, respectively, one nail breakage at removal, two cases with minor humeral shortening, and two cases with minor varus deformity. At the final (14.6-month) follow up all patients had a symptom-free full range of motion. Elastic stable intramedullary nailing is a valid method of treating severely displaced proximal humeral fractures in children.     

Treatment of ipsilateral hip and femoral shaft fractures with reconstructive intramedullary interlocking nail

Objective: To evaluate the results of reconstructive intramedullary interlocking nail in the treatment of ipsllateral hip and femoral shaft fractures. Methods: From August 1997 to November 2001, 13 patients were treated with the reconstructive intramedullary interlocking nail. Nine patients were associated with ipsllateral femoral neck fractures, three with ipsilateral intertrochanteric fractures, and one with subtrochanteric fracture. Results: The follow-up time was from 6 to 38 months with an average of 14 months. All the femoral shaft and hip fractures healed up well. There was no nonunion of the femoral neck, and only one varns malunion. No patient had avascular necrosis of the femoral head. The average healing time for femoral neck fracture was 4.6 months and for shaft fracture 5.8 months. The joint movement and other functions were fairly resumed. Conclusions: The reconstructive intramedullary interlocking nail, with less trauma, refiable fixation, and high rate of fracture healing, is an ideal method of choice in the treatment of ipsilateral hip and femoral shaft fractures.     

Intramedullary Kirschner wire (K-wire) fixation of femoral fracture in children

Purpose The aim of this study was to evaluate the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of femoral shaft fracture in children. Methods We report the results of intramedullary K-wires nailing in 178 children with a mean age of 7.7 years (range, 4–14 years) from 2000 to 2005, retrospectively. A total of 184 diaphyseal femoral fractures were treated with both antegrade and retrograde nailing using the same principles of elastic stable intramedullary nailing (ESIN). The patients were followed for 12 months on average (range, 6–24 months). Results No major complication (limb length discrepancy >15 mm, non-union, avascular necrosis, knee joint stiffness) occurred during the observation period. All fractures healed within 7.1 weeks on average (range, 5–12 weeks). Associated injuries were seen in 16.9% of the cases. All but seven fractures were reduced by closed manipulation. Early mobilization and weight bearing was allowed. Intramedullary K-wires were removed after an average of 4.8 months (range, 3–12 months) without any complications. Conclusions In children, intramedullary fixation by using standard K-wires provides effective treatment for the diaphyseal femoral fracture that has excellent clinical results. Each intramedullary K-wire costs US $5, which adds a cost effective advantage to this method of treatment.     

Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion.

OBJECTIVE: A new intramedullary nail system for humeral shaft fractures is evaluated to determine whether retrograde nailing is as reliable as antegrade nailing. STUDY DESIGN: Prospective multicenter nonrandomized clinical study. PATIENTS: Eighty-four patients with acute humeral shaft fractures were nailed with the new unreamed humeral nail (UHN) system. Fifty-seven nails were introduced retrogradely, and twenty-seven antegradely. Bone healing and functional outcome were the follow-up parameters. RESULTS: The ratio of perioperative complications was equivalent for both groups, but one shaft fracture and three fractures or fissures at the entry point occurred in the group with retrograde nail insertion. Five fractures, all with retrograde nail insertion, needed secondary surgery to achieve bony healing. There was no difference in functional outcome after healing in either group. CONCLUSION: Retrograde nailing of humeral shaft fractures is technically more demanding than antegrade nailing. Fractures or fissures at the insertion point must be avoided by adequate preparation of the entry hole and careful nail insertion. Bone healing problems seem more surgeon-related than approach-related. As in every other procedure, an optimal fracture configuration and high fracture stability must be achieved.     

股骨重建钉治疗股骨干合并同侧髋部骨折适应证探讨

目的探讨股骨重建钉治疗股骨干合并同侧髋部骨折的手术适应证。方法根据入选标准和排除标准,回顾2001年1月至2011年1月收治的股骨干合并同侧髋部骨折病例15例,其中男14例,女1例;年龄21~64岁,平均35.5岁。通过比较术前、术后即刻、术后1、3、6和12个月的临床和影像学随访结果,评估骨折愈合情况和并发症,分析股骨重建钉治疗股骨干合并同侧髋部骨折的最佳适应证。结果全部病例获得随访,随访时间14~48个月,平均27.8个月。13例股骨干骨折一期获得骨性愈合,愈合时间(6.2±4.1)个月,14例股骨颈骨折一期获得骨性愈合,愈合时间(5.4±2.9)个月。合并症:1例股骨远端骨折由于狭部限制,重建钉过细,局部旋转不稳定,并发肥大性骨不连;1例股骨中段骨折延迟愈合;2例股骨干旋转畸形愈合;1例股骨颈头下型骨折不愈合。末次随访时进行Friedman-Wyman评定,优12例,良2例,差1例,优良率93.3%。结论股骨重建钉适用于绝大部分股骨干骨折合并髋部骨折,尤其是股骨颈基底部骨折合并股骨干近端或狭部骨折。但对于股骨颈头下型、难复位的股骨颈骨折合并股骨干远端骨折,股骨重建钉并非最佳的治疗方案。     

Tibial shaft fractures in children and adolescents

Tibial shaft fractures are among the most common pediatric injuries managed by orthopaedic surgeons. Treatment is individualized based on patient age, concomitant injuries, fracture pattern, associated soft-tissue and neurovascular injury, and surgeon experience. Closed reduction and casting is the mainstay of treatment for diaphyseal tibial fractures. Careful clinical and radiographic follow-up with remanipulation as necessary is effective for most patients. Surgical management options include external fixation, locked intramedullary nail fixation in the older adolescent with closed physis, Kirschner wire fixation, and flexible intramedullary nailing. Union of pediatric diaphyseal tibial fractures occurs in approximately 10 weeks; nonunion occurs in <2% of cases. Some clinicians consider sagittal deformity angulation >10 degrees to be malunion and indicate that 10 degrees of valgus and 5 degrees of varus may not reliably remodel. Compartment syndromes associated with tibial shaft fractures occur less frequently in children and adolescents than in adults. Diagnosis may be difficult in a young child or one with altered mental status. Although the toddler fracture of the tibia is one of the most common in children younger than age 2 years, child abuse must be considered in the young child with an inconsistent history or with suspicious concomitant injuries.     

The role of reamed intramedullary nailing in the treatment of nonunions and malunions following femoral shaft fractures

Summary This retrospective consecutive clinical series describes our satisfactory experience with reamed intramedullary femoral nailing in the treatment of nonunions, axial or rotational deformities as well as length discrepancies following the primary treatment of femoral shaft fractures. 31 patients (32 fractures) treated at our institution from 1992 to 1997 were reviewed for age, gender, cause of injury, type of femur fracture, primary treatment, indication for secondary nailing, operative procedure, complications, need for additional procedures and time for consolidation. 3 patients were lost for follow-up, leaving 28 patients (29 fractures) for evaluation. The average follow-up was 79 weeks (range 24 to 192). The indications for secondary nailing were: 18 nonunions, 7 rotational or axial deformities, 4 length discrepancies. Consolidation was achieved in 25 patients (26 fractures) at an average time of 38 weeks (range 12 to 104). Nonunion was recorded in 3 patients. They were treated successfully with an additional procedure (one exchange intramedullary nailing and two autologous bone grafts). The reamed intramedullary interlocking nail offers many advantages, especially a good initial and middle term stability which is important in case of a slow process of consolidation. By the treatment of atrophic and long lasting nonunion, simultaneous bone grafting seems to be indicated. We conclude that interlocking reamed femoral nailing is a safe treatment option for nonunions and malunions following primary treatment of femoral shaft fractures, resulting in successful union without additional procedure in 26 of 29 fractures in this series.     

Trochanteric nail insertion for the treatment of femoral shaft fractures

OBJECTIVES: This study was designed to evaluate whether the use of a new femoral nail, specifically designed to be inserted through the greater trochanter, could eliminate the complications previously seen with insertion of straight nails through this entry portal for the treatment of femoral shaft fractures. DESIGN: Prospective, clinical trial. SETTING: Three level I trauma centers. PATIENTS: Sixty-one consecutive patients with femoral shaft fractures (50 closed and 11 open fractures) treated with antegrade nailing with insertion through the greater trochanter. INTERVENTION: All patients were treated in the supine position with a TAN nail (Trigen System, Smith & Nephew, Memphis, TN) inserted through the greater trochanter. MAIN OUTCOME MEASURE: Union, alignment, complications, and hip function. RESULTS: Forty-six of 57 (81%) surviving patients were available for follow-up at a minimum of 12 (range, 12-25) months. Union occurred in all but 1 fracture after the index procedure. No patient sustained iatrogenic fracture comminution, and there were no angular malunions. Pain was reported as slight in 6 patients and moderate in 2. Visual and videotaped gate analysis, performed on 24 patients, revealed symmetrical walking in 21. CONCLUSIONS: This study demonstrates that antegrade nailing of femoral shaft fractures with a specially designed nail inserted through a trochanteric starting point provides predictably high union rates and low rates of complications. Ease of entry and utility in patients with a large body habitus are advantages over conventional piriformis fossa entry techniques. Nailing through the greater trochanter with the patient supine is presently our treatment of choice for patients with femoral shaft fractures.